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<body>   
        <div class="context">
            <div id="u6377">
                <select name="" id="">
                    <option value="">异常用药事件</option>
                    <option value="">医疗医技异常事件</option>
                    <option value="">护理异常事件</option>
                    <option value="">输血不良反应</option>
                    <option value="">医疗器械异常事件</option>
                    <option value="">药物不良反应事件</option>
                    <option value="">感染病例报告卡计</option>
                    <option value="">行政与后勤保障事件</option>
                    <option value="">治安管理异常事件</option>
                </select>
            </div>
            <div id="u5936">
                <div></div>
            </div>
            <div id="u5937">
                <span>1.&nbsp;&nbsp;  暂存数据：保存填写的数据，下次可以进行补充修改，但是并没有提交。</span>
            </div>
            <div id="u5938">
                <span>填表声明</span>
            </div>
            <div id="u5944">
                <span>2.&nbsp;&nbsp;  确认数据：保存填写的数据并提交各质控科室，不可再次修改。</span>
            </div>
            <div id="u5943"></div>
            <div id="u5939"></div>
            <div id="u5940">
                <span>异常用药报告填写</span>
            </div>
            <div id="u5942"></div>
            <div id="u5941">
                <div></div>
                <span>&nbsp;&nbsp;&nbsp;患者基本情况</span>
            </div>
            <div id="u5946">
                <span>病历号:</span>
                <span style="margin-left: 14px;color: #ff0000;">*</span>
            </div>
            <div id="u5947">
                <span>病人信息:</span>
            </div>
            <div id="u6005">
                <span>所在科室：</span>
            </div>
            <div id="u5955">
                <span>入院日期：</span>
                <span style="margin-left: 4px;color: #ff0000;">*</span>
            </div>
            <div id="u5956">
                <span>临床诊断:</span>
            </div>
            <div id="u6378">
                <input type="text" placeholder="请输入正确的病历号后回车（门诊为就诊卡号）">
            </div>
            <div id="u5949">
                <span>姓名</span>
            </div>
            <div id="u5948">
                <input type="text" style="width: 130px;height: 35px;">
            </div>
            <div id="u5950">
                <span>性别</span>
            </div>
            <div id="u5953">
                <select name="" id="" style="width: 130px;height: 35px;">
                    <option value="">男</option>
                    <option value="">女</option>
                </select>
            </div>
            <div id="u5952">
                <span>年龄</span>
            </div>
            <div id="u5951">
                <input type="text" style="width: 130px;height: 35px;">
            </div>
            <div id="u6006">
                <select name="" id="" style="height: 35px;width: 540px;">
                    <option value="">妇科</option>
                    <option value="">内分泌科</option>
                    <option value="">儿童心理科</option>
                    <option value="">儿科</option>
                    <option value="">产科</option>
                    <option value="">神经外科</option>
                    <option value="">眼科</option>
                </select>
            </div>
            <div id="u6002">
                <input type="date" placeholder="请选择日期" style="width: 540px;height: 35px;">
            </div>
            <div id="u5957">
                <input type="text" style="width: 540px;height: 90px;" name="" id="">
            </div>
            <div id="u6093">
                <div></div>
                <span>&nbsp;&nbsp;&nbsp;患者基本情况</span>
            </div>
            <div id="u6057">
                <span>是否匿名上报：</span>
                <span style="margin-left: 4px;color: #ff0000;">*</span>
            </div>
            <div style="position: absolute;left: 362px;top: 655px;">
            <label class="radio-inline">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 否
            </label>
            <label class="radio-inline">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 是
            </label>
            </div>
            <div id="u6008">
                <span>是否匿名上报：</span>
                <span style="margin-left: 4px;color: #ff0000;">*</span>
            </div>
            <div id="u6053">
                <input type="date" placeholder="请选择日期" style="width: 540px;height: 35px;">
            </div>
            <div id="u6073">
                <span>事件发生日期类型：</span>
            </div>
            <div id="u6074">
                <select name="" id="" style="height: 35px;width: 540px;">
                    <option value="">---请选择---</option>
                    <option value="">工作日</option>
                    <option value="">法定节假日</option>
                    <option value="">休息日</option>
                </select>
            </div>
            <div id="u6060">
                <span>事件发生的场所：</span>
                <span style="margin-left: 4px;color: #ff0000;">*</span>
            </div>
            <div style="position: absolute;left: 362px;top: 783px;">
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 门诊
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 急诊
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 住院
                </label>
            </div>
            <div style="position: absolute;left: 362px;top: 809px;">
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 手术麻醉
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 产房
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 医技科室
                </label>
            </div>
            <div style="position: absolute;left: 362px;top: 835px;">
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 公共活动区
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 场所不明
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 其他场所
                </label>
            </div>
            <div id="u6076">
                <span>事件发生的环境状态：</span>
            </div>
            <div style="position: absolute;left: 362px;top: 866px;">
                <select name="" id="" style="height: 35px;width: 540px;">
                    <option value="">---请选择---</option>
                    <option value="">照明昏暗</option>
                    <option value="">地面湿滑</option>
                    <option value="">走廊拥挤</option>
                    <option value="">其他</option>
                </select>
            </div>
            <div id="u6091">
                <span>事件发生前患者所处的状态<span style="color: #ff0000;">*</span>：（可多选）</span>
            </div>
            <div style="position: absolute;left: 362px;top: 916px;">
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox1" value="option1"> 意识障碍
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox2" value="option2"> 听觉障碍
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox3" value="option3"> 视觉障碍
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox3" value="option3"> 语言障碍
                </label>
            </div>
            <div style="position: absolute;left: 362px;top: 945px;">
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox1" value="option1"> 精神障碍
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox2" value="option2"> 肢体功能障碍
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox3" value="option3"> 感觉障碍
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox3" value="option3"> 特殊疾病障碍
                </label>
            </div>
            <div style="position: absolute;left: 362px;top: 975px;">
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox1" value="option1"> 麻醉状态
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox2" value="option2"> 服用药物后
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox3" value="option3"> 治疗过程中
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox3" value="option3"> 公共服务设施
                </label>
            </div>
            <div style="position: absolute;left: 362px;top: 1004px;">
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox1" value="option1"> 正常行走中
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox2" value="option2"> 床上安静休息
                </label>
                <label class="checkbox-inline">
                    <input type="checkbox" id="inlineCheckbox3" value="option3"> 其他
                </label>
            </div>
            <div id="u6096">
                <span>错误药品是否发给患者：<span style="color: #ff0000;">*</span></span>
            </div>
            <div style="position: absolute;left: 362px;top: 1034px;">
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 否
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 是
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 不详
                </label>
            </div>
            <div style="position: absolute;left: 362px;top: 1095px;">
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 否
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 是
                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 不详
                </label>
            </div>
            <div id="u6101">
                <span>患者是否使用了错误药品：<span style="color: #ff0000;">*</span></span>
            </div>
            <div id="u6105">
                <span>给患者造成损害的轻重程度：</span>
            </div>
            <div id="u6106">
                <span>Ⅰ级：发生错误，造成患者死亡</span>
            </div>
            <div style="position: absolute;left: 362px;top: 1179px;">
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">I级：导致患者死亡
                </label>
            </div>
            <div id="u6108">
                <span>Ⅱ级：发生错误，且造成患者伤害</span>
            </div>
            <label class="radio-inline" style="position: absolute;left: 362px;top: 1238px;">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">E级：造成患者暂时性伤害，并需要进行治疗或干预
            </label>
            <label class="radio-inline" style="position: absolute;left: 362px;top: 1268px; margin-left: 0px;">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">F级：造成患者暂时性伤害，并需要住院或延长住院时间
            </label>
            <label class="radio-inline" style="position: absolute;left: 362px;top: 1298px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">G级：造成患者永久性伤害
            </label>
            <label class="radio-inline" style="position: absolute;left: 362px;top: 1328px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">H级：导致患者需要治疗挽救生命
            </label>
            <div id="u6113">
                <span>Ⅲ级：发生错误，但未造成患者伤害</span>
            </div>
            <label class="radio-inline" style="position: absolute;left: 362px;top: 1387px;">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">B级：发生但未累及患者
            </label>
            <label class="radio-inline" style="position: absolute;left: 362px;top: 1417px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">C级：累及到患者，但没有造成伤害
            </label>
            <label class="radio-inline" style="position: absolute;left: 362px;top: 1447px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">D级：累及到患者，需要进行监测以确保患者不被伤害，或需通过干预阻止伤害发生
            </label>
            <div id="u6117">
                <span>Ⅳ级：错误未发生（错误隐患）</span>
            </div>
            <label class="radio-inline" style="position: absolute;left: 362px;top: 1507px;">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2">A级：客观环境或条件可能引发不良事件（隐患）
            </label>
            <div id="u6119">
                <span style="color:#1E1E1E;">事件分类：</span><span style="color:#FF0000;">*</span>
            </div>
            <div id="u6120"> 
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">警讯事件：
            </div>
            <div id="u6122"> 
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">不良后果事件：
            </div>
            <div id="u6124"> 
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">未造成后果事件：
            </div>
            <div id="u6126"> 
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">临界差错事件：
            </div>
            <div id="u6121">
                <span>涉及死亡或严重身体伤害或心理伤害的意外事件。严重身体伤害具体包括丧失四肢或功能。</span>
            </div>
            <div id="u6123">
                <span>造成机体或功能的损害的事件。</span>
            </div>
            <div id="u6125">
                <span>虽然发生了错误事实，但未造成不良后果。</span>
            </div>
            <div id="u6127">
                <span>任何发现的缺陷或错误，未形成事实，未造成危害，但其再发生很有可能带来严重后果。</span>
            </div>
            <div id="u6132">
                <span style="color:#1E1E1E;">事件科目：</span><span style="color:#FF0000;">*</span>
            </div>
            <label class="radio-inline" style="position: absolute;top: 1672px;left: 362px;">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 处方错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1720px;left: 362px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 调剂错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1766px;left: 362px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 书写错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1814px;left: 362px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 给药技术错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1864px;left: 362px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 给药顺序错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1912px;left: 362px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 用药依从性错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1958px;left: 362px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 用药指导错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 2006px;left: 362px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 药品摆放错误
            </label>
            <label class="radio-inline" style="position: absolute;top: 2057px;left: 362px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 给药剂量错误
            </label>
            <label class="radio-inline" style="position: absolute;top: 1672px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 处方传递错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1720px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 药物配制错误
            </label>
            <label class="radio-inline" style="position: absolute;top: 1766px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 患者身份识别错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1814px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 用药时间/时机错误
            </label>
            <label class="radio-inline" style="position: absolute;top: 1864px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 遗漏错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 1912px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 监测错误
            </label>
            <label class="radio-inline" style="position: absolute;top: 1958px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 药品储存不当事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 2006px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 秩序错误、系统错误事件
            </label>
            <label class="radio-inline" style="position: absolute;top: 2057px;left: 639px;margin-left: 0px">
                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 其他事件
            </label>
            <div id="u6161">
                <input type="text" style="height: 35px;width: 156px;" name="" id="">
            </div>
            <div id="u6187">
                <span>事件发生的原因（可多选）：</span><span style="color:#FF0000;">*</span>
            </div>
            <label class="checkbox-inline" style="position: absolute;top: 2108px;left: 362px;margin-left: 0px">
                <input type="checkbox" id="inlineCheckbox1" value="option1"> 处方因素
            </label>
            <label class="checkbox-inline" style="position: absolute;top: 2155px;left: 362px;margin-left: 0px">
                <input type="checkbox" id="inlineCheckbox1" value="option1"> 环境因素
            </label>
            <label class="checkbox-inline" style="position: absolute;top: 2203px;left: 362px;margin-left: 0px">
                <input type="checkbox" id="inlineCheckbox1" value="option1"> 其他
            </label>
            <div id="u6200">
                <input type="text" style="width: 156px;height: 35px;" name="" id="">
            </div>
            <label class="checkbox-inline" style="position: absolute;top: 2108px;left: 639px;margin-left: 0px">
                <input type="checkbox" id="inlineCheckbox1" value="option1"> 药品因素
            </label>
            <label class="checkbox-inline" style="position: absolute;top: 2155px;left: 639px;margin-left: 0px">
                <input type="checkbox" id="inlineCheckbox1" value="option1"> 人员因素
            </label>
            <div id="u6214">
                <span style="color:#1E1E1E;">药品相关</span>
                <span style="color:#FF0000;">*</span>
            </div>
            <div id="u6215">
                <span>增</span>
            </div>
            <div id="u6217">
                <span>编</span>
            </div>
            <div id="u6216">
                <span>删</span>
            </div>
            <div id="u6212">
                <span style="color:#1E1E1E;">事件经过：</span>
                <span style="color:#FF0000;">*</span>
            </div>
            <div id="u6211">
                <input type="text" style="width: 540px;height: 90px;" name="" id="">
            </div>
            <div id="u6241">
                <span>有无药品标签、处方复印件等资料：</span>
            </div>
            <div id="u6202">
                <span style="color:#1E1E1E;">不良后果：</span>
                <span style="color:#FF0000;">* </span>
            </div>
            <div id="u6205">
                <span style="color:#1E1E1E;">医疗纠纷：</span>
                <span style="color:#FF0000;">* </span>
            </div>
            <div id="u6268">
                <span style="color:#1E1E1E;">补救措施：</span>
                <span style="color:#FF0000;">* </span>
            </div>
            <div id="u6211" style="position: absolute;left: 362px;top: 2566px;">
                <input type="text" style="width: 540px;height: 90px;" name="" id="">
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                </label>
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                    <option value="">---请选择---</option>
                    <option value="">无</option>
                    <option value="">有</option>
                    <option value="">不详</option>
                </select>
            </div>
            <div style="position: absolute;left: 362px;top: 2480px;">
                <select name="" id="" style="height: 35px;width: 94px;">
                    <option value="">---请选择---</option>
                    <option value="">无</option>
                    <option value="">有</option>
                    <option value="">不详</option>
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            <div id="u6267">
                <div></div>
                <span>&nbsp;&nbsp;&nbsp;补救措施</span>
            </div>
            <div id="u6270">
                <div></div>
                <span>&nbsp;&nbsp;&nbsp;当事人基本情况</span>
            </div>
            <div id="u6300">
                <div></div>
                <span>&nbsp;&nbsp;&nbsp;报告者基本情况</span>
            </div>
            <div id="u6271">
                <span>当事人编号：</span>
            </div>
            <div id="u6273">
                <span>所在科室：</span>
            </div>
            <div id="u6277">
                <span>引起错误的人员：</span><span style="color:#FF0000;">* </span>
            </div>
            <div id="u6284">
                <span>其他与错误相关人员：</span><span style="color:#FF0000;">* </span>
            </div>
            <div id="u6292">
                <span>发现错误相关人员：</span><span style="color:#FF0000;">* </span>
            </div>
            <div id="u6276">
                <span>当事人所处的状态：</span>
            </div>
            <div id="u6272">
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            <div style="position: absolute;top: 2767px;left: 362px;">
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                    <option value="">妇科</option>
                    <option value="">内分泌科</option>
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                    <option value="">儿科</option>
                    <option value="">产科</option>
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            <div style="position: absolute;left: 362px;top: 2904px;">
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                </label>
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                </label>
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 护士
                </label>
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                    <option class="u6275_input_option" value="---请选择---">---请选择---</option>
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                    <option class="u6275_input_option" value="过劳">过劳</option>
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                <span>报告人信息：</span>
            </div>
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                <span>联系信息：</span>
            </div>
            <div id="u6322">
                <span>单位信息：</span>
            </div>
            <div id="u6307">
                <span style="color:#1E1E1E;">姓名</span>
                <span style="color:#FF0000;">*</span>
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                <span style="color:#FF0000;">*</span>
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                <span style="color:#FF0000;">*</span>
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                <span style="color:#1E1E1E;">民族</span>
                <span style="color:#FF0000;">*</span>
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                <span style="color:#1E1E1E;">职业</span>
                <span style="color:#FF0000;">*</span>
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                <span style="color:#1E1E1E;">电子邮箱</span>
                <span style="color:#FF0000;">*</span>
            </div>
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                <span style="color:#1E1E1E;">签名</span>
                <span style="color:#FF0000;">*</span>
            </div>
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            </div>
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            </div>
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            </div>
            <div style="position: absolute;left: 428px;top: 3255px;">
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            </div>
            <div style="position: absolute;left: 704px;top: 3255px;">
                <input type="text" style="width: 200px;height: 35px;" name="" id="">
            </div>
            <div style="position: absolute;left: 428px;top: 3308px;">
                <input type="text" style="width: 200px;height: 35px;" name="" id="">
            </div>
            <div style="position: absolute;left: 704px;top: 3308px;">
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            </div>
            <div style="position: absolute;left: 428px;top: 3357px;">
                <input type="text" style="width: 200px;height: 35px;" name="" id="">
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            </div>
            <div style="position: absolute;left: 701px;top: 3212px;">
                <label class="radio-inline">
                    <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 医师
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                <label class="radio-inline">
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                <label class="radio-inline">
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                </label>
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            <div id="u6323">
                <span>单位名称</span>
            </div>
            <div id="u6325">
                <span>联系人</span>
            </div>
            <div id="u6327">
                <span>电话</span>
            </div>
            <div id="u6329">
                <span>报告日期</span>
            </div>
            <div style="position: absolute;top: 3425px;left: 484px;">
                <button type="button" class="btn btn-warning" style="width: 200px;height: 40px;">确定提交</button>
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